NYC Crisis Response Discussion Paper - For Distribution

Responding to a Psychiatric Emergency:
A Vision for Public Health Reform in New York City
A Discussion Paper by Community Access
Introduction
On June 22, 2018, the Mayor’s Task Force on Crisis Prevention and Response was
convened with the charge to “…develop [a] comprehensive, citywide strategy to prevent
mental health crises and improve the City’s response to emotionally distressed New
Yorkers.”1 By December 2018, the Task Force participants had met several times and
issued a set of draft recommendations, which will become the basis of a future strategic
plan to create a new and improved crisis response system. 2
Because a final plan has yet to be formulated, we believe this is an opportune moment to
review the many plans and initiatives launched by the current administration for improving
mental health care and the degree to which those initiatives can assist people with
behavioral health challenges, thousands of whom lead an uncertain existence cycling
through shelters, jails, hospitals, and the streets.
The compelling motivation for creating the current crisis response task force was to
improve the city’s response during and following 911 calls. Despite instituting a
comprehensive crisis training program in 2015, police officers continue to struggle to
adequately assist people deemed “emotionally disturbed persons,” or EDPs (a pejorative
term that contributes to the de-humanization of people in need of help). As a result, there
have been unnecessary injuries to officers and people in need, as well as nine police-
involved killings of people in distress between 2015 and 2018.
Viewed broadly, we believe these traumatic encounters between the police and people in
crisis are the consequences of a social support and public health system that fails to:
1
https://www1.nyc.gov/office-of-the-mayor/news/203-18/mayor-de-blasio-first-lady-mccray-launch-nyc-crisis-prevention-
response-task-force
2
See https://www.communityaccess.org/crisis-discussion-paper for Task Force presentations and its membership. Its
draft recommendations, distributed to the members on December 14, 2018, are not available for public distribution by
Community Access. All inquiries should be directed to Ayesha Delany-Brumsey, Ph.D., Dir of Behavioral Health
Research and Programming, Mayor’s Office of Criminal Justice. adelanybrumsey@justice.nyc.gov
Responding to a Psychiatric Emergency: A Vision for Public Health Reform in New York City Page 1 of 20
1) provide assistance to people well before a 911 call is made, and
2) provide adequate support after the encounter with emergency services, during
which people may be in jail, hospitals, or shelters.
Without effective interventions, this expensive and frustrating cycle repeats itself, leaving
police officers to cope with a social problem that was not of their making, and for which
they receive very little training or support.3
The time period after calling 911 often results in chaotic scene in which persons in crisis
and their friends and family—who probably requested help in the first place—lose much
of their decision-making authority. The “best case” outcome in this situation typically
includes the person in crisis being handcuffed and sent to a psychiatric emergency room,
which is an even more chaotic setting for someone who needs exactly the opposite.
Developing new and better solutions to both reduce the number of crises in the first place,
and to respond effectively afterwards, will require sustained commitment across multiple
mayoral terms. It will also require creative problem solving, accurate data, and
engagement with a broad spectrum of stakeholders—including those members of our
community who have been homeless, incarcerated, and subject to mental health care.
This also means working closely with the communities most affected by the challenges of
long-term poverty and racism. It is a simple fact that people of color are overly
represented in our shelters, public hospitals, and jails. Addressing the social determinants
of health4 that produce this disparity is essential for creating a truly just and effective long-
term strategy.
Improving and repairing the crisis response system is really an opportunity to create a
community-based health care and social support system that responds to our most
vulnerable citizens when and where they need assistance.5
3
The Crisis Intervention Team training, the most comprehensive preparation available, is only 40 hours, which is far less than
the four to five years of schooling and training devoted to obtaining a clinical social work degree.
4
Lack of housing, stress, poverty, and social isolation all contribute to poor health outcomes.
www.euro.who.int/__data/assets/pdf_file/0005/98438/e81384.pdf,
5
See Attachment 2 for A Note On Involuntary Treatment
Campaign for Reforming Police Training Organizes in 2012
Anticipating the election of a new mayor in 2013, an advocacy campaign was launched in
October 2012 called Communities for Crisis Intervention Teams.6 The campaign’s goal
was to bring attention to this issue and to educate the candidates, and the public in general,
about alternatives to the city’s approach, starting with enhanced training for police
officers. Called Crisis Intervention Team (CIT) training, it was originally developed in
Memphis in 1986 and has been adopted in some form by over 3,000 other communities.7
Bill de Blasio was elected mayor in November 2013 and in December the mayor-elect
named William Bratton as the new Police Commissioner, replacing Raymond Kelly, who
had consistently resisted calls for reform of police training and tactics. Commissioner
Bratton, who had previously been NYC’s Police Commissioner between 1994 and1996,
brought fresh experiences and ideas from his stint as the Los Angeles Chief of Police
between 2002 and 2009.
During Bratton’s tenure in Los Angeles, the city expanded CIT training, created a special
mental health triage unit to assist officers in the field, and adopted co-response teams that
paired officers with trained clinicians. We were optimistic that the new Commissioner
would be responsive to the CIT Campaign’s reform agenda.
Mayor’s Task Force on Behavioral Health and Criminal Justice
Our hopes for a change in police training and protocols were realized within a few months.
In June 2014 Mayor de Blasio formed the first-ever Task Force on Behavioral Health and
Criminal Justice. By December 2014 the Task Force issued a comprehensive Action Plan
to:
…address how the criminal justice and health systems can work together better to
ensure that we are reserving criminal justice resources for the appropriate cases and
deploying treatment and other proven effective remedies to interrupt those
needlessly cycling through the system.8
The report noted that while the overall jail population had decreased by 15% over the
previous five years, the percentage of people in jail with “mental health issues” rose from
29% to 38%, meaning the number of people with a mental health challenges in jail actually
increased over this period from around 3,500 to over 4,000.
6
See www.ccitnyc.org.
7
See www.cit.memphis.edu
8
BF and CJ Action Plan 2014 also at: https://www.communityaccess.org/crisis-discussion-paper
This trend has only increased: in 2016, 42% of the people in jail had a “confirmed” mental
health diagnosis.9
More and more, our jails are becoming de facto psychiatric facilities.
The Action Plan was a well-conceived proposal to reverse this trend by diverting people
with behavioral needs into treatment and away from the criminal justice system. Notably,
the Plan relied heavily on proven approaches that had been widely embraced elsewhere
and promoted by the Council of State Governments Justice Center under its Stepping Up
Initiative.10
Central to the Justice Center’s approach is the sequential intercept model:
…when appropriate, individuals with behavioral health needs:
 do not enter the criminal justice system in the first place;

 if they do enter, that they are treated outside of a jail setting;
 if they are in jail, that they receive treatment that is therapeutic rather than
punitive in approach; and that
 upon release, they are connected to effective services.11
Over 20 different recommendations were described in the Action Plan, from enhancing
police training and creating community diversion centers, to adding behavioral teams in
probation departments to reduce recidivism.
Below is a diagram of a sample sequential intercept strategy.12 Note the “Intercept 0” box,
which references community-based crisis prevention strategies, was not included as a
recommendations in the Action Plan, but has been part of the Thrive NYC initiative
(described below).
9
https://rikers.wpengine.com/wp-content/uploads/Justice-Brief_Jail-Population_.pdf
10
https://csgjusticecenter.org/mental-health/county-improvement-project/stepping-up/
11
ibid
12
https://www.prainc.com/sim/
In July 2015 the city issued the first and only progress report on implementation of the
Action Plan.13 Of the 24 recommendations (See Attachment 1), some were identified as
being 100% complete, such as “Establish a working group to coordinate all discharge
planning,” and “Provide specialized services to adolescents.”
Unfortunately, verifying the accuracy of these claims is not possible without specific data.
For instance, related to discharge planning, the report states that an “…electronic system
has been created that shares appropriate information about clients being served by each
agency, which helps to avoid duplication of services.” If this system has been established,
is it working? How many people have been helped and how?
One area of easily documented improvement has been the Report’s first recommendation:
“Expand training for first responders to recognize behavioral health needs.” The
responsibility for the new program was given to the NYPD, which adopted the “Memphis
model” of CIT training: a method that features small classes and 40 hours of intensive
examination of mental health issues from the perspective of people who have experienced
both psychiatric crises and encounters with police officers. By December 2018 over
10,000 officers had been trained.14
Progress on a companion recommendation, opening community-based diversion centers,

was reported as 25% complete: “…in the spring of 2016, the first of two clinical drop-off
community centers will open. These centers will provide an important alternative to jail or
hospitalization, assess needs and provide short-term care.”
After a failed RFP process in 2015, the city issued a solicitation for a negotiated
acquisition in 2016,15 after which two vendors were selected to operate centers in the
Bronx and East Harlem. On December 7, 2018, the Mayor’s Office issued a press release
announcing that these centers are now projected to open in late 2019.16
No further Status Reports were published related to the

Action Plan and the web link to the original Plan itself has
been taken down.
Learn more at nyc.gov/bhtf
13
Called the “First Status Report,” it implied that subsequent reports would be issued.
https://www.communityaccess.org/crisis-discussion-paper
14
NYPD Quarterly Stakeholders meeting, December 17, 2018
15
Notice of Solicitation https://www.communityaccess.org/crisis-discussion-paper
16
Locations of Two Planned City Health Diversion Centers https://www.communityaccess.org/crisis-discussion-paper
Of greater concern than the lack of transparent reporting around the Action Plan, has been
the continued police-involved shootings of people who are experiencing an emotional
crisis. Between June 2015 and January 2018, at least nine people were shot by officers
responding to 911 crisis calls .17
We believe many of these incidents could have been prevented with better planning and a
coordinated implementation strategy based on existing best practices. Several
recommendations of this type have, in fact, been offered to the city but have not been
implemented.
In 2016, the Mayor’s Office of Criminal Justice commissioned a review of its Action Plan
by the Council of State Government Justice Center (CSGJC).18
CSGJC review, while generally positive, identified several areas of possible improvement,
including the 911 call center:
Implement a division of NYPD that oversees all specialized behavioral health

responses by the NYPD. A division that oversees all behavioral health responses in
the NYPD could help to ensure that there is consistency in responses.
Create a standard set of questions for 911 dispatchers to ask to identify whether the
call is related to a mental health crisis.
Establish a triage desk to assist with all 911 calls coming into NYPD identified as a
behavioral health crisis calls.
911 dispatch should develop a protocol to divert responses to the Mobile Crisis Unit,
i.e., a non-officer response.
Other communities have instituted similar, best practice reforms that have allowed them to
better track why people are calling for 911 assistance and, in some instances dispatch
specially trained crisis workers instead of police officers.19 Also, identifying repeat
callers means interventions can be arranged to assist people who would otherwise use 911
as their de facto health care resource.
Growing frustrated with the city’s slow progress on implementing the Action Plan—or at
least the lack of transparency in what was actually being accomplished—the CCIT
17
https://www.amny.com/news/mental-health-nypd-1.16925317
18
Brief Assessment of New York City’s Behavioral Health and Criminal Justice Systems, November 2016, also here:
19
Cahoots program, Eugene, OR. https://whitebirdclinic.org/wp-content/uploads/2018/11/20181125-wsj-cahoots.pdf
coalition pushed for the city to reactivate the original task force to re-examine the action
plan and develop a new approach that would:
 be informed by all stakeholders, including people who had been subject to police
interactions,
 have clearly defined objectives backed by data, and
 issue regular reports outlining progress on the plan’s implementation.20
Responding to the attention generated by the coalition and to requests from the city
council, in April 2018 the mayor’s office announced that new task force was going to be
created.21
Mayor’s Task Force on Crisis Prevention and Response
On June 22, 2018, Mayor de Blasio convened a second task force related to mental health
issues, this one to address the specific issues connected with 911 calls and their aftermath.
This is an issue that is consuming a tremendous amount of public resources: In 2017

there were 170,000 calls related to “…an apparent mental health crisis.” In 57% of the
cases a person was transported to a hospital, either with a NYPD officer (43%) or solely
with EMS (14%). Further, the trips to emergency rooms and hospitalization rates are
uneven across the city and fall most heavily on communities of color with high rates of
poverty and other social challenges.
The Task Force included over 80 individuals, drawn from city agencies, hospitals, legal
services, and community-based organizations. Community Access’s Advocacy
Coordinator, Carla Rabinowitz, and CEO, Steve Coe, were both active members.22
The overall charge for the Task Force was to develop a comprehensive strategy to improve
the City’s 911 response to people in mental health crisis and was summarized as follows:
1. When there is a call to 911 for a mental health crisis, what can we do to improve the
response?
2. What supports can we connect people to in order to avoid future mental health crisis
calls to 911?
Within this broad mandate, four strategy areas were described:

20
https://www.ny1.com/nyc/all-boroughs/news/2017/10/18/activists-call-on-city-to-reactivate-task-force-on-mental-health-
and-policing-on-anniversary-of-fatal-shooting
21
https://nycprogressives.com/2018/04/20/progressive-caucus-statement-on-the-formation-of-mayors-edp-task-force/
22
https://www1.nyc.gov/office-of-the-mayor/news/203-18/mayor-de-blasio-first-lady-mccray-launch-nyc-crisis-prevention-
response-task-force
 Prevent mental health crises before they happen: develop strategies and supports to
prevent crises, including community and family support, peer engagement and
respite services.
 Enhance coordination between the City’s safety and health systems: create
strategies that allow better coordination between our health and public safety
systems.
 Enhance ongoing support to reduce mental health crises over the long-term: develop
services to prevent future crises, such as intensive engagement, connection to
ongoing support and treatment, enrollment in benefits, and help with housing and
employment.
 Share data across systems to refine the approach over time: develop sustainable
ways to share data and to monitor and analyze the effectiveness of these strategies.
The Task Force adopted the following guiding principles, which make explicit the role that
race and poverty play in contributing to the differences in accessing services and the value
of including citizens who have been closest to the issue in developing solutions:
 Ensure the advancement of racial equity and improve outcomes for communities of
color
 Meaningfully include people with lived experience of the crisis system in the design
and operation of the crisis system
 Invest in community capacity to design and operate supports for people who
experience crises
Initially, the members for the Task Force were divided into four self-selected
subcommittees: prevention, early intervention, response, and post-stabilization. These
subcommittees met twice during summer and generated a list of 35 preliminary
recommendations, which fell into four broad groups:
 Prevention: Enhanced Services at the Community Level

 Crisis Response: First Responder Protocols
 Crisis Response: Service Alternatives to ERs
 Implementation: Need for an Independent Oversight Body
While the ideas were all sensible, the preponderance of the recommendations dealt with
prevention and enhancing community resources. Again, we believe there are some
significant opportunities to decrease the use of 911 as a crisis tool if there were more
access to appropriate community-based resources.
Overall, we applaud the goals of the Task Force and its broad mandate to develop
comprehensive, long-term strategies for a truly effective crisis response system. Such a
system will not only save millions in unnecessary police and emergency services costs but
will produce better outcomes for people who need access to compassionate and responsive
treatment.
The challenge moving forward will be to develop a plan and oversight system that will
ensure that proposed initiatives and strategies live up to key principles and remain flexible
so that new ideas can be tested, revised, and expanded based on objective criteria and solid
data analysis.
And as will be discussed below, there was consensus that an independent oversight body
needs to be created that can execute and sustain a reform effort over the course of multiple
administrations.
As was stressed to the Task Force in December:
“Work remains to edit, refine, determine which [recommendations] will be adopted, and
develop operational plans.”23
Conclusions
1. Behavioral health crises are a public health issue, not a law enforcement and criminal
justice problem.
The 170,000 mental health-related 911 calls made in 2017 were the symptom of a public
health system that is not helping people cope with complex social, economic, and chronic
health issues at a much earlier point. Improving the skills and protocols of first-
responders, while important to reduce the violence and trauma people in crisis often
experience, will not fundamentally create an alternative pathway for more effective care.
Many of the recommendations that flowed from the recent Task Force acknowledge this
fact and suggest many possible strategies that add new options. Such options include
community-based behavioral urgent care and respite centers, alternative forms of crisis
response, and enhanced training for local institutions that people already trust and use.
23
Presentation: Crisis Prevention and Response Task Force, Full Work Group Meeting, December 14, 2018:
There are many examples of different diversion models throughout the U.S. and elsewhere
that should be studied for testing and possible replication.
2. User feedback is essential.
Any strategic plan created by the city policy makers should be informed by direct user
input, which means people who have experienced crises, their friends and family
members, and local community institutions.
This approach goes by many names, such as Community-led Development (CLD), a

planning and development approach that incorporates five core principles.24
1. Grow from shared local visions

2. Build from strengths
3. Work with diverse people and sectors
4. Grow collaborative local leadership
In 2017, Mayor’s Office of Criminal Justice undertook such a planning process, called the
Neighborhood Activation Study: Crime Prevention Through Community Design and
Problem-Solving.25 The project conducted in-depth research in two precincts with the
highest rates of serious crime, asthma and diabetes, low educational achievement and
employment – the 42nd in Morrisania and the 73rd in Brownsville. For the 42nd precinct
alone, over 30 different community-based organizations were interviewed, as well as
hundreds of neighborhood residents.
Similar community-led strategic plans focused on racial equity and social justice—key
principles of the Task Force—have been undertaken in other communities. In King
County, Washington, the community has created a six-year plan that shifts “…away from
policies and practices that react to problems and crises toward investments that address the
root causes of inequities…”26 A key feature of their planning process was deep
engagement with all stakeholders, from government employees to community members.
Reforming Crisis Services in NYC: A Community Forum27
To help inform our understanding of the issues from a users’ perspective, Community
Access convened a Community Forum on January 18, 2019 and invited people who have
had a personal experience with a 911 call, or a police interaction during a crisis, either as a
24
http://inspiringcommunities.org.nz/resources/about-cld/principles/
25
https://criminaljustice.cityofnewyork.us/reports/neighborhood-activation-study/
26
https://www.racialequityalliance.org/2017/04/06/king-county-built-strategic-plan-equity-social-justice/
27
www.communityaccess.org/crisisservicesforum
peer, family member, or community-based organization working closely with people who
have frequent contacts with the police. Over 70 people responded.
The focus of the forum was to review and distill the many ideas (over 40) that had been
generated by the task force between June and December. We did not rank or suggest
which ideas had been presented as the final recommendations at the December 14 task
force meeting. We asked the group to create a list of five to seven recommendations that
they felt should be included in a crisis response plan. The group was also free to develop
any new ideas that had not already been put forward.
Following a three-hour brainstorming and sorting session, the group came to a consensus
around the following items:
1. Change the Number: Alternatives to Calling 911

• The new number should be easy to remember
• Create an environment that changes how people think about and respond to crises
• Engages community in the fight against stigma
• Fewer calls to police/fewer police interactions with people in mental health crisis
and reduce number of potentially violent interactions
• Previous success: “311” rollout
2. Create Alternatives to Hospitals

• Respites: 7-14 day stays
• Diversion Centers
• Mental Health Urgent Care Centers
• Mental health team + peers
• Similar to urgent care when one cuts a finger
• Incorporate Mental Health into all existing medical care centers
• Safe havens
• Improve shelters
• Should not evict people during the day
• Changing the culture of shelters to be recovery oriented
• Involving shelter residents in decisions about the shelters and employing
shelter residents during the day
• Drop-in centers like senior & youth centers
3. Expand Mental Health Education and Training

• Community awareness of existing resources
• Community education about mental health in schools and communities
• Examples include outreach to: houses of worship, community centers, via
ThriveNYC, libraries, social media, and local community organizations, community
boards, and schools
• Eliminate stigma – more conversation
• Create more understanding & acceptance
• Creates recognition & possible prevention
• Creates relationships among neighbors to protect neighbors without placing blame
• Know what to look for/recognize
• Highlights common ground – you’re not alone
4. Expand CIT and De-escalation Training

• Select police officers who exhibit the skill set to work with mental health recipients
in distress
• Conduct annual refresher training
• Conduct annual basic training for de-escalation and stigma-busting training for all
officers and rookies
• Include an array of instructors with a mind to cultural diversity for all training
• Encourage mental health disclosure by instructors of CIT training
• Looking beyond police to include all safety and security officers in NYC
government agencies
5. Peer Involvement
• Involve peers at all levels of implementation of task force
• Engage peers in policy discussions and policy decision-making of NYPD and the
city relating to CIT
• Increase salaries and supports for peers in CIT work, as with other professionals
• Increase access of peers in CIT work to well-designed training: recovery training,
cultural competence, and ethics
6. Alternatives to Police Responding to 911 Calls

• People in distress calls are most often health concern issues that need either social
workers or peers, not law enforcement. One would not expect the police to be able
to treat high cholesterol, police should not be solving mental health support calls.
• Include trained peers in the 911 call center to assist in screening and responding to
callers requesting mental health support
• Peer-to-peer work has proven results in improving the lives of peers.
• Trained peers have strong track records in de-escalating mental health crisis
issues.
• Peers understand the importance of respectful communication, especially in
working with people in distress.
• Most peers are trained in trauma informed care and can respond without re-
escalating the trauma of the person in distress.
This very brief forum and brainstorming session was in no way a substitute for genuine
community input. The 70-odd people and organizations we assembled could be multiplied
by a factor of 100 to generate even more ideas.
In the end, a well-conceived strategic plan “…can make government more responsible and
accountable because it is all based on the desires and feedback of community partners,
residents and employees.”28
3. The creation of an independent planning body to oversee a vast and long-term reform
effort is essential.
Developing and implementing a comprehensive, multi-year strategic plan cannot be

accomplished within the span of a single administration. As an example, two highly-
regarded jail diversion programs, one in San Antonio (Bexar County), Texas and the other
Miami-Dade County, were launched almost two decades ago following a collaborative
community-wide planning process.
In April 2002, a stakeholders meeting was convened in Bexar County [Texas] with
the representation from 22 city, county, and state law enforcement, judicial, and
health care entities. The result of the collaboration was the development of a
comprehensive Jail Diversion Program Model, under the direction of The Center for
Health Care Services (CHCS), the mental health authority in Bexar County.
The Bexar County Jail Diversion Program, December 200429
In the year 2000, the Eleventh Judicial Circuit [Miami-Dade County]

Criminal Mental Health Project was created. Under the leadership of the
Honorable Steven Leifman, Associate Administrative Judge, Circuit Court
Criminal Division, partnerships were formed with the Florida Department of
Children and Families (DCF), Jackson Memorial Hospital (“JMH”), The
National Alliance for the Mentally Ill (“NAMI”), several police departments
and the criminal courts. The goal was to develop better ways of dealing with
the number of repeat misdemeanor offenders who suffered from mental
illness and were coming in contact with the criminal justice system.
Final Report of the Miami-Dade County Grand Jury, Spring 2004 30
28
https://www.racialequityalliance.org/2017/04/06/king-county-built-strategic-plan-equity-social-justice/
29
Bexar County Jail Diversion Program, Michael Johnsrud, PhD
Replicating elements of these successful programs will require a similar multi-agency and
community collaboration effort to plan, implement, and monitor the progress of the overall
program. The Miami-Dade program has been operating under the jurisdiction of the court
system, a unique arrangement that is probably not possible elsewhere.
One example on an independent planning body might be found in Baltimore County,

which created Baltimore Crisis Response, Inc., 501(c)3 established by the Baltimore
County Mental Health System.31
No matter the eventual entity that is created to develop and oversee the implementation of
a strategic plan, the key stakeholders who informed the plan must continue to be engaged
and informed about its progress. An example of such a program is the Diversion First
initiative in Fairfax County, VA. Launched in 2015, the county holds regular stakeholder
meetings with detailed reports covering each aspect of the plan. And unlike the missing
links to the NYC Action Plan mentioned above, all the references and meeting reports can
be found on the County’s Diversion First site.32
In Miami-Dade, the director of the court’s Mental Health and Police Collaboration project
coordinates two to three meetings per year. Attendance is mandated for all receiving
hospitals (21) and CIT liaisons from every police department (30), and also includes peers,
providers, court and government officials.33
4. Human-centered planning that allows the City to start small and scale up will ensure
greater flexibility and effectiveness.
Developing new services or products with the customer as the primary beneficiary is a
common practice in business and relies on a set of tools to carefully define the problem,
generate dozens of possible strategies, and systematically test, review, and re-test the most
practical approaches.
In the public and social sectors, however, this approach is rarely employed. Instead,
planners often develop a “solution” without thoroughly testing its merits and ask providers
to respond to an RFP to execute the plan. The resulting program commits the provider to a
rigid “scope of services” and a corresponding line item budget that are extremely hard to
amend.
30
www.miamisao.com/publications/grand_jury/2000s/gj2004s.pdf
31
https://bcresponse.org
32
https://www.fairfaxcounty.gov/topics/diversion-first/references.
33
For more information, contact: Habsi Kaba, Director of CIT Miami-Dade and Police Mental Health Collaboration 11th
Judicial Circuit Criminal Mental Health Project at hkaba@jud11.flcourts.org.
An alternative, non-linear, approach starts small and iterates fast. Using structured
problem-solving techniques found in human-centered design, or design thinking, frequent
user feedback is solicited for each new version of a service or product. New approaches
that eventually meet a degree of positive consensus from stakeholders can be tested in the
field and further measured and evaluated before taken to scale—at which point a request
for proposals may be the best approach.34
As part of the “solution-finding” process, the city needs to evaluate and measure the many
other mental health-related initiatives it currently has underway, which could directly
support a crisis strategy and the recommendations cited above, especially as they relate to
enhanced community-based supports and crisis prevention.
Two program areas of note include Thrive NYC and the newly-created Center for Racial
Equity. The former is directed within the Mayor’s Office and the latter is a division of
city’s Department of Health and Mental Hygiene, meaning they have completely separate
leadership, budget authority, and strategic oversight. These two programs alone contain
over 50 separate initiatives.
Bringing all the city’s initiatives into a coordinated strategic plan, under centralized
leadership, will be critical for the overall success of any reform effort. As is the case with
Miami-Dade and Bexar Counties, mentioned above, there are many state and local
agencies responsible for the funding the oversight of these initiatives. 35
A fully realized crisis response system was described in a monograph prepared in 2005 by
the Technical Assistance Collaborative, called the Community-Based Comprehensive
Psychiatric Crisis Response Service.36 The report stresses the need to view a crisis
response system as part of the large public health and social support network:
There is growing recognition that psychiatric crisis services cannot and do not
operate on the fringe of the health care system, but rather are mainstream
activities necessary to complete the health care continuum. Crisis services cut
across many different systems, including:
 Social services: Housing, medical benefits, child welfare, etc.;
 Legal: Detainment for the purpose of treatment and evaluation;
 Health: Medical services; and
34
An excellent review of this approach is Lean Impact: How to Innovate for Radically Greater Social Good
https://leanstartup.co/social-good/
35
See ThriveNYC: A Roadmap for Mental Health for All and A Service Matrix distributed to the Crisis Task Force that
outlines several of programs and services related to improving crisis services: https://www.communityaccess.org/crisis-
discussion-paper
36
http://www.tacinc.org/knowledge-resources/publications/manuals-guides/crisis-manual/
 Community and personal safety: Law enforcement assessment of
danger to self or the community37
5. The City must focus on social determinants of health, especially stable living situations
that may not necessarily be an apartment with a lease.
A stable living situation is probably the single most critical factor in preventing crises from
occurring in the first place and assisting people access the wide array of financial and
social supports needed to live successfully in the community. While the city and state
each have extremely ambitious supportive housing initiatives, the need far outstrips the
production capacity of these programs.
One approach is to reform the shelter system, especially the mental health shelters, to
make them more attractive options for people. Improvements would include private, or
semi-private rooms, ample community space to accommodate a range of activities, and
recovery-oriented services and training opportunities.
Greatly expanding the Department of Homeless Services’ Safe Haven

program should also be considered. These are small-scale facilities
specifically targeted to homeless individuals who may be resistant to
accepting other services, including traditional shelters. There are currently
1,200 Safe Haven beds for men and women.
“Safe Havens are equipped with on-site services and outreach staff who work closely with
clients to deepen relationships, help stabilize their lives, and, ultimately, encourage them to
transition further off the streets and into permanent housing.”38
Summary
The city is on the verge of creating a new plan to tackle an extremely complex social
problem, one that has bedeviled the best efforts of many communities.
The good news is that there are projects and initiatives around the country that are
working, that is, reducing the violence inflicted on people experiencing an emotional
crisis, successfully diverting people with behavioral needs from the criminal justice
system, and creating a range of service options that allow consumers a choice in the type
of help they want to use. Many of the most effective programs have relied on a best-
37
ibid
38
https://www1.nyc.gov/site/dhs/about/press-releases/safe-haven-tour-advisory.page
practices type framework, such as the Stepping Up Initiative developed by the County of
State Governments Justice Center.39
In addition to service models, there are better ways to plan, implement, measure, and
execute a new approach. We have mentioned a few ideas in this paper, but we would
encourage the city to engage with experts that have produced good results for other
communities. One such project, called “Aging By Design: Design Days,” was developed
by a human-centered design firm, Overlap Associates,40 and was commissioned by the
Health Foundation of Western and Central New York to improve services for vulnerable
older adults.41 This project has:
“…reached more than 4,000 older adults and 700 caregivers and has resulted
in fewer falls, improved Timed Up and Go (TUG) scores, reduced home
hazards and increased awareness of risks among older adults.42
Another example is a project to reduce jail recidivism developed by the human-centered

design firm, DC Design, and the County of Santa Clara. 43 The design process led to the
“…Santa Clara County Reentry Network, an organization composed of the

key leaders in the county criminal justice system — the Sheriff, the District
Attorney, the Public Defender, a County Supervisors, the Director of Reentry
Services, the Head of Parole, the Director of Behavioral Health and 20 other
leaders and community members.”44
Finally, racial and social justice considerations need to be at the core of any solution that
hopes to address the challenges faced by people who are in frequent contact with the
mental health and criminal justice system. For this to happen, the investigation into what
will truly help people needs to include a “…significant focus [on] learning about people’s
lives outside of service.”45
_________________________________________________________________________
39
https://stepuptogether.org/
40
https://www.overlapassociates.com/about-overlap/
41
https://hfwcny.org/program/aging-by-design/
42
https://hfwcny.org/program/step-stop-falls/
43
https://medium.com/dc-design/is-building-more-jails-the-answer-to-californias-prison-problems-a0f8e046cdd3
44
Applying Design Thinking to the Criminal Justice System and DC Design Santa Clara County Reentry Services Findings and
Recommendation Report https://www.communityaccess.org/crisis-discussion-paper
45
http://designingbetter.ca/why-we-did-it/
About Community Access
Community Access is a pioneer of supportive housing and social services in NYC for
people with mental health concerns. As part of our core mission we lead advocacy efforts
that promote human rights, social justice, and economic opportunities for all. For further
information go to www.communityaccess.org or phone 212-780-1400 x7711.
Steve Coe
CEO
scoe@communityaccess.org
January 2019
Attachment 1
Behavioral Health Task Force First Status Report – June 2015
Attachment 2
A Note on Involuntary Treatment
Some pundits have blamed the closing of the state’s large psychiatric centers as the culprit
for today’s scourge of overburdened psychiatric emergency rooms, courts, and jails.46 If
there were more “treatment beds” available, the reasoning goes, people would get the help
they needed and be able to live in a protected environment that would serve their best
interests and that of society at large.
Building “asylums” (from Greek, meaning “refuge”) is a social experiment that has been
attempted many times over the centuries and the outcomes are always the same—well-
meaning crusaders are eventually replaced by administrators, the institutions compete for
scarce funding, and what began as a place to restore people instead becomes a human
warehouse.47 And, since the Olmstead ruling,48 such an approach is considered an
unconstitutional violation of basic human rights.
It is also a fact that involuntary services, be they inpatient or outpatient (such as Kendra’s
Law orders), are not race-neutral and fall disproportionately on low-income people of
color, as a quick visit to any public psychiatric hospital or jail will confirm.
Rejecting hospitals does not mean the opposite; let people in need cope as best they can.
Until we create a range of community-based options and supports—few of which exist
today—and enough affordable housing for everyone who needs a home, we should not be
contemplating more restrictive options. And, even for people who absolutely require a
protected environment, building and operating small-scale residences remains far more
humane and cost-effective than the state-run facilities of the past.49
46
https://mentalillnesspolicy.org/insane-consequences.html
47
See Joint Commission Accredited More Than 100 Psychiatric Hospitals Despite Abuses:
48
https://en.wikipedia.org/wiki/Olmstead_v._L.C.
49
A unit in a small-scale (under 16 beds), well-funded, licensed community residence cost $100,000 annually versus $250,000
for a public hospital bed and is eligible for Medicaid funding under current law.

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Responding to a Psychiatric Emergency:

A Vision for Public Health Reform in New York City

A Discussion Paper by Community Access

Mayor’s Task Force on Behavioral Health and Criminal Justice

Central to the Justice Center’s approach is the sequential intercept model:

…when appropriate, individuals with behavioral health needs:

 do not enter the criminal justice system in the first place;

Progress on a companion recommendation, opening community-based diversion centers,

No further Status Reports were published related to the

Implement a division of NYPD that oversees all specialized behavioral health

Mayor’s Task Force on Crisis Prevention and Response

This is an issue that is consuming a tremendous amount of public resources: In 2017

Within this broad mandate, four strategy areas were described:

 Prevention: Enhanced Services at the Community Level

As was stressed to the Task Force in December:

2. User feedback is essential.

This approach goes by many names, such as Community-led Development (CLD), a

1. Grow from shared local visions

Reforming Crisis Services in NYC: A Community Forum27

1. Change the Number: Alternatives to Calling 911

2. Create Alternatives to Hospitals

3. Expand Mental Health Education and Training

4. Expand CIT and De-escalation Training

6. Alternatives to Police Responding to 911 Calls

Developing and implementing a comprehensive, multi-year strategic plan cannot be

The Bexar County Jail Diversion Program, December 200429

In the year 2000, the Eleventh Judicial Circuit [Miami-Dade County]

Final Report of the Miami-Dade County Grand Jury, Spring 2004 30

One example on an independent planning body might be found in Baltimore County,

Greatly expanding the Department of Homeless Services’ Safe Haven

Another example is a project to reduce jail recidivism developed by the human-centered

“…Santa Clara County Reentry Network, an organization composed of the

Behavioral Health Task Force First Status Report – June 2015

A Note on Involuntary Treatment

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